Inequities in Access and Delivery of Acute Stroke Care: A Brain Attack Coalition Symposium

How is it acceptable that the fate of your brain depends on where you live? Most hospitals in the United States can provide acute stroke treatments that are life-saving and prevent life-long disability. However, the key to a successful outcome is to immediately recognize stroke symptoms and call 911 so that hospital treatments can be delivered within a few hours. Sadly, many people across the country do not receive these acute stroke treatments 1. Living in a rural community is just one of several factors that can impact an individual’s quality of care. Even with the latest technologies and treatments at our fingertips, policies, regulations, financial burdens, limited resources, and other issues prevent individuals from getting the stroke care they need.

To address these inequities, NINDS sponsored a symposium of the Brain Attack Coalition (BAC) titled Inequities in Access and Delivery of Acute Stroke Care earlier this year, and has now released its final symposium report(pdf, 755 KB). Held from March 17-18, 2022, the virtual event brought together public health and stroke experts to define the current scope of inequities in acute stroke care and understand their root causes and major contributors. The event was moderated by Mark Alberts, M.D., Chief of Neurology at Hartford Hospital and founder of the Stroke Belt Consortium, and Richard Benson, M.D., Ph.D., Director of the NINDS Office of Global Health and Health Disparities (OGHHD). BAC members and teams of experts in the field shared their findings from a literature review on current equity issues, known and unknown causes or obstacles, and best practices for organizing systems of acute stroke care. Inequities were examined through the lens of three time epochs: prehospital care, acute care in an emergency department setting, and in-hospital or inpatient care.

Over 150 registrants participated in lively breakout sessions, where they raised new ideas and offered insightful feedback about barriers to quality stroke care, new avenues for research, and policy changes to overcome those barriers. In the proceeding months, NINDS and expert task forces worked diligently to incorporate this feedback into a report, which details recommendations and action opportunities for addressing inequities across the stroke care continuum. My hope is that these findings will pave a path forward to improving equity in stroke care. I invite you to read the report(pdf, 755 KB).

The BAC is a group of fifteen professional organizations representing every specialty of stroke care. For over 30 years, this group has led nationwide efforts to advance stroke knowledge and communicate best practices regarding stroke prevention and treatment. In the 1990s, the BAC published some of the most impactful stroke guidelines in the field, leading to the establishment of national quality measures for primary stroke centers, comprehensive stroke centers, and acute stroke ready hospitals across the country. These guidelines greatly contributed to the widespread use of safe, effective treatments, including the intravenous clot-busting drug tissue plasminogen activator (tPA), highly effective intra-arterial clot removal devices, as well as the emergency care of persons with bleeding into the brain (intracerebral hemorrhage) and around the brain (subarachnoid hemorrhage). The findings discussed in the 2022 report will build upon this foundational work by bringing knowledge, treatments, technologies, and stroke expertise to everyone, including high-risk individuals, through a health equity lens.

At the symposium, prehospital care emerged as a main focus because deficiencies in early recognition, triage, and transport have major downstream impacts on patient outcomes. Systems for acute stroke care involving multiple hospitals tied together by telemedicine and teleradiology, along with ambulance and helicopter transport of emergency cases, need to be scaled up nationwide. Among the disparities, the task forces noted a lack of knowledge about stroke risk factors, poor recognition of stroke symptoms, and an underutilization of 911, especially among those in minority populations and underserved groups. In the emergency department epoch, speakers reported a lack of access to high-level stroke centers and stroke expertise, particularly in rural areas of the country. In the hospital setting, there are significant disparities in the use of secondary stroke treatment measures and acute rehabilitation services, especially among minorities and women.

As symposium speakers summarized their discussions, it became clear that several disparities exist in all levels of stroke care, from stroke recognition to hospital discharge. For example, calling 911 may be perceived as having a “high price tag” or unnecessary, and may deter individuals from using emergency medical services (EMS). Similarly, secondary stroke medications and rehabilitation may also be seen as too costly or troublesome. Telemedicine has shown great promise in the acute care setting, but telestroke services are not used widely enough in healthcare systems across the country. Further, the stroke care workforce—including EMS professionals, stroke neurologists, and neurosurgeons—is not fully representative of the people they serve. Involving persons with lived experience from the community, establishing diversity committees, networking and recruitment opportunities, and removing financial barriers might help to ensure that the stroke care workforce more closely resembles those that they serve.

To move forward, how do we address these disparities? Fortunately, there are several opportunities to resolve these issues. In the short term, one key recommendation was to develop a regional and/or national stroke registry that could provide key insights into the factors associated with disparities, allowing comprehensive study of the effectiveness of stroke care nationwide. The task forces also suggested relaunching culturally sensitive approaches to public education about stroke, noting the NINDS Mind Your Risks campaign as a model. Partnerships between state-health offices, federal agencies, advocacy groups, and others might also help address disparities. The full report(pdf, 755 KB) details many other potential solutions.

Overall, more research is needed to better understand today’s disparities in stroke care. To name a few opportunities, encouraging more targeted research on the effectiveness of telestroke and mobile stroke units and on disparities in medication noncompliance, building up “trust” in the health care and research enterprise, as well as leveraging or optimizing current research resources, such as NINDS Common Data elements, may set us in the right direction. We are fortunate that Dr. Benson leads our OGHHD office, which, as I wrote previously, is coordinating and developing programs and initiatives that foster global health research and research on health disparities in neurological disorders and stroke. These topics and others were considered as part of the NINDS health equity strategic planning process.

Prior to 1995, acute ischemic stroke was not a treatable condition. With the advent of tPA, stroke care shifted from supportive care to the rapid identification of ischemic stroke and treatment eligibility. More recently, technological advancements in diagnostic imaging, revascularization devices, and telestroke have expanded our ability to provide highly effective treatments if they are delivered within hours of stroke onset. Now, it’s time to ensure that these life-saving treatments and technologies are available to all in an equitable manner. I look forward to a future where high-quality stroke care, delivered by talented and diverse teams of stroke care professionals, is a reality for all populations. Hopefully, this report, among other efforts led by members of the BAC, will offer a path forward.

Learn more about the BAC, and to watch the full symposium, recordings are available on the event page.

Related References

[1] HEADS-UP: Understanding and Problem-Solving, Seeking Hands-Down Solutions to Major Inequities in Stroke. Ovbiagele, Bruce. 2020, Stroke, pp. 3375-3381.